Saturday, November 23, 2002

Note: For the video, scroll down to the bottom of the linked page and click on the movie links. The first has a lot of talking heads, but at the end there’s a very moving scene when a woman tries out the iBot for the first time. The other two have excellent footage of the iBot’s capability. The last one is the best.
P.S. Your computer isn't broken. The videos don't have sound.

Drug Ad Business II: Not content with making slick television and print ads, and other fancy marketing tools, the ad agencies are now doing their own drug research. The ad companies defend the practice by citing the saintliness of medical journals. Surely, the editors of JAMA, NEJM, the Lancet, and BMJ, won’t let biased research into their pages:

Advertising executives note that scientific trials are tightly regulated and that most medical journal articles get careful review. Doctors, they say, are hungry for information about new drugs.

But articles don’t get all that much careful review. Too often the review process only serves to make sure the study is well-designed. It doesn’t search for bias. And too often, the editors let the authors inflate their statistically significant findings to make them seem clinically significant, when they clearly aren’t. Heck, sometimes they let them pronounce the statistically insignificant as significant. (By calling it a "trend") This sort of sloppiness is common, and it passes without any sort of editorial comment from the journals.

In fact, sometimes the editorials are biased themselves. When Redux was being introduced to the market, the New England Journal of Medicine had an editorial about how its benefits outweighed its risks. Only later did it come to light that the authors of the editorial had financial ties to the makers of Redux. And of course, much later Redux found itself in trouble over fatal side effects. It’s a mistake to think that just because a paper gets published that it’s unbiased, or that it’s conclusions are valid. And it's a mistake to give a paper a pass just because it's published in one of the more prestigious journals.

Then there’s the re-writing of review articles to favor a marketing company’s drug, as in the case of Ritalin:

The drug company's advisers at Intramed, a medical education company owned by the global ad giant WPP, had a solution. They would take an article, commissioned from two university professors, that objectively surveyed a wide range of drugs and rewrite it to emphasize the potential benefits of a drug with the characteristics of Ritalin LA.

The Times article has all the details on this - from transcripts of a conference call between the original authors and the ad agency to an interview with the woman who was hired to ghost write it. Her conscience has motivated her to quit:

"I don't have any problem with medical advertising that states in a clear way, either by format or by copy, this is an advertisement," she said. "What I mind is advertising that calls itself education."

Right. And here’s another take on the same thing by a former editor of the New England Journal of Medicine:

"We don't get anywhere in medicine without objective data," he said. "That's the coin of the realm. The whole purpose of medical research is lost if you don't tell the truth."

And don’t think that marketing doesn’t matter. Here’s what it’s done for a new antidepressant, Lexapro, one of those “copy-cat” drugs invented to foil a patent expiration:

"Based on the number of prescriptions written in Lexapro's first weeks on the market, the analysts said that Forest appeared on its way to one of the best new product launches in the industry's history.

"This market does respond to promotion," Kenneth E. Goodman, Forest's president, said in a conference call with Wall Street analysts on Oct. 15. Forest invested so much in promotion that Lexapro was the subject of 63 percent of all industry-sponsored meetings that primary care doctors reported attending in an October survey by ImpactRx, a consulting firm.

Last year, just $2.8 billion of the $11.8 billion the drug industry spent on marketing was aimed at consumers; the rest paid for everything from dinner meetings with doctors to sales calls and medical education, according to Verispan, a health-care information company.

That’s a lot of money. Money that could be going to feed research chemists rather than doctors. But, of course, the short term profits of feeding research chemists don’t approach those of feeding doctors.

Blog Breakdown:RangelMD is having problems with his blog, and says he'll be down indefinitely until and if things get fixed. Don't go away, Rangel! Keep posting, it's the ideas that matter, not the look of the page. If push comes to shove, start one on Blogspot. I know everyone complains about them, but they're free and easy to use, and they don't break down all that often.

See, I think the autopsy and the exhibitions are good things - I like that these things are available for the public to see. Without seeing the exhibit, I can't say exactly how "educational" it is, but let's assume that von Hagen's work is at least on the level of, say, bill nye the science guy,
whose "educational" program is 99% presentation and 1% science - since when is it bad for people to see what's inside their bodies?

But, you already said you agree with, as you put it, the medical education of the public.

Sure, you don't *need* to do what he does when computer simulations are available, but come on. You also don't need to go to art galleries when there are pictures of the same paintings on the internet. For that matter, you don't really *need* to see the inside of the body at all if you're not a med student.

But you know what? I think it's a good thing art galleries exist - a picture of a painting is nothing in comparison to the real thing, and while I went on every surgery / anatomy lab / museum field trip I could in high school, and loved every minute of it, I've never seen a computerized dissection that
didn't bore me to tears. And I *like* computers.

The cadavers are willing participants, and since everybody involved (vn hagens, the people formerly in the bodies, and the audience) are all OK with it, what's the harm?

I think the art museum analogy is very applicable. Do museums "cheapen" art? Does anybody leave a museum with less respect for the paintings that when they came in? Does it matter whether the museum charges admission?

I probably didn’t express myself well in the previous posts about this. My objection isn’t that he charges money. And of course there’s no problem with art museums. They don’t cheapen art, even when they charge admission. What’s at question is whether or not this is art, and whether it’s of any educational value. I don’t think it is either of those things, and I suspect if he were honest with himself, the professor doesn’t think so, either. His treatment of bodies is ghoulish and morbid, and not done with any modicum of the respect that the dead deserve. He cheapens death, and in so doing cheapens life.

Yes, it’s true that his bodies are donated, but judging from his donation form (pdf), he goes to great pains to make people think their bodies will be treated with respect and dignity and used for educational purposes rather than entertainment:

I am aware that the IfP is a private institute. It is run by the inventor of plastination, Prof Gunther von Hagens. Prof von Hagens has undertaken to use human specimens exclusively for research and educational purposes, and only to give them directly to educational establishments, such as universities, hospitals and museums, but not to private individuals. . [emphasis mine]

How many of those donors do you suppose read “museum” and thought “art museum”? The form is worded to suggest they’ll go to natural history museums or medical museums or science museums. In fact, I wouldn’t have any objection to the use of them for such purposes, as long as they were treated respectfully. They aren’t treated respectfully in his art exhibit, though, as a glance through its web page makes abundantly clear. (there's more here.) That is my sole objection to him. He’s a sensationalist, not an educator. And his use of corpses is better expressed by this picture than by Rembrandt’s.

Friday, November 22, 2002

Worst Wishes: Just when I was thinking the blogosphere was an uncommonly civil place, I get my first hate mail:

Slicing on a dead body to educate an ignorant public bothers you, but it's OK for parents to kill a child with leukemia by refusing to take him in for treatment with an 85% cure rate! No ethical issues there. You need a new head- perhaps Von Hagens could find one for you...

I thought I made it pretty clear in the post that if the treatment were less toxic, if the child weren't in remission, and if there were a better cure rate, then the parents would be guilty of negligence. But, these people weighed the risks and the benefits and decided the risks were too much. It isn't as if they were denying him life-saving antibiotics for meningitis. Anyone who has read this blog knows that I'm no fan of "alternative medicine," but I also don't think we should use our position to bully people.

Furthermore, Professor Von Hagen isn't doing his public autopsy for educational purposes. In this age of MRI and virtual cadavers, you don't need to flay open a corpse in public to teach people about the human body. It's pure sensationalism. I have nothing against the medical education of the public. If I did, I wouldn't write this blog.

Lawyers have filed a class-action lawsuit against McDonald's on behalf of New York children who have suffered health problems, including diabetes, high blood pressure, and obesity.

In federal court in Manhattan on Wednesday, a lawyer alleged that the fast-food chain has created a national epidemic of obese children. Samuel Hirsch argued that the high fat, sugar and cholesterol content of McDonald's food is "a very insipid, toxic kind of thing" when ingested regularly by young kids.

Herbal Med Watch: The EU is considering a ban on herbal medications, or at least tighter restrictions. That's interesting. For years, advocates of herbal medicines have used the "they've been used for years in Europe" defense, as if that alone made them safe and efficacious.

DOA: Some say that a body with a pulse was pulled from the freezer of the DC morgue. I doubt it. When they hooked the body up to a monitor, there wasn't any heart activity. No heart activity, no pulse, and certainly no life. Still, they should have had someone certify the death before they put the body in a plastic bag and the freezer.

More On Dying in America: A reader forwarded these comments on the Last Act survey:

I read their report. It looks like some sensible people who wrote some
overly dramatic eye grabbers that have then become the entire story.
Their actual recommendations are mostly ordinary sensible stuff. I
suspect it would not have been reported as news if they had simply
issued it as an update of recommendations. Almost half the report is
eye grabbing excess.

The most serious flaw in their hospice section is that they ignore the
home hospice effort. I know that locally there is strong pressure to
accept home hospice services rather than dedicated hospice rooms. In
most cases this is consistent with what the patients want. This leads
to a drop in duration for dedicated hospice stay, as is noted in their
report.

They also are using rather poor statistical methodology. If you want to
measure hospices you should measure waiting lists and vacancies. The
optimum is no waiting lists, so everyone gets in when they want to, and
few vacancies, so money is not wasted on excess construction or operating costs.

That’s true about the home hospice programs. Those are very popular with the terminally ill, and they allow people to meet their goal of dying peacefully at home. It's hard to understand why the report would ignore home hospice, unless their goal is to make it seem like the hospice movement is being ignored. The pdf version of the report is here.

Quirky Museum Watch: A virtual tour of the Meguro Parasitological Museum in Japan. (It’s a rough virtual tour, but the picture of the scrotal elephantiasis is worth it. For purely ecucational purposes, of course.)

The first wheelchair that can climb stairs - plus shift into four-wheel drive to scoot up a grassy hill and even elevate its occupant for eye-level conversation - took a major step toward the market Wednesday, as advisers to the Food and Drug Administration unanimously recommended it be allowed to sell.

Wow. Users might have to get a license to use it, though. And a loan to buy it. ($29,000)

Anatomy Lessons: I’ve been trying to figure out why the mad performance art doctor elicits such a visceral reaction in me. Is his public autopsy any different than the one portrayed by Rembrandt? Are the plasticized corpses and body parts that make up his Body Worlds exhibit any different than the eighteenth century anatomical wax models? While it’s true that artists have relied on dissection and anatomy lessons to enable them to create beautifulart, and while it’s true that some public autopsies were little more than performances, it’s also true that past behavior is no excuse for present behavior. Public executions used to be commonplace, too, but few people would want to go back to the days of gallows-lined roads. Professor Von Hagen’s “art” isn’t so much a step into a brave new world as it is a step back to a more brutal time.

Medicine has changed a lot since the days of Rembrandt, not only in the advancement of its science, but in the advancement of its heart. Once, it was acceptable for medical students to casually debase their cadavers. Today, medical students would be expelled for such behavior. Perhaps the medical profession has taken the lessons of the Nazi doctors, with their blatant disregard for the dignity of the living and the dead, to heart.

Professor Von Hagen treats his bodies in much the same way those earlier medical students treated theirs - as entertainment, and his supply of corpses may not be all that different from Rembrandt's anatomist's. His work should give us all pause. It cheapens death, and in so doing cheapens life.

Thursday, November 21, 2002

Mad Doctor Update: The German-pathologist - turned- performance-artist, Professor von Hagens, performed his public autopsy to a record crowd, and to a television audience, too. The British aren't sure yet whether they'll prosecute him for violating their Anatomy Acts. Whether or not it's illegal, it certainly breaches the bounds of medical ethics. Although the corpse was donated to the doctor for purposes of art by its original inhabitant when he was still alive, let's be honest about this. The audience was there purely as voyeurs. And the professor knows this. He's not doing this for "art" but for money. He is a circus perfomer, not an artist or an educator.

In a study of 2,392 young women, half of them vaccinated and half given placebo shots, the vaccine was 100 percent effective. Followed for 17 to 27 months, no vaccinated women developed infections or precancerous growths from the virus, whereas 41 nonvaccinated women did become infected, including 9 with precancerous cervical growths.

The infection rate for unvaccinated women is admittedly low (41 out of 765), but that zero percent infection rate in the vaccinated is pretty hard to beat. The study focused on only one variant of human papilloma virus, HPV-16, which is has the highest association with cervical cancer of all its relatives, and it only looked at women because the focus of the vaccine is to prevent cervical cancer. HPV, however, is also a disease of men. It causes genital warts, and it can cause cancer of the rectum, anus, and penis, although these don’t occur with anywhere near the frequency of cervical cancer. It would be interesting to know, however, how the vaccine behaved in men. If it worked well in them, too, vaccinating both men and women could help eliminate HPV all together.

Interestingly, the same issue of the NEJM, includes a study that tests the efficacy of a vaccine against genital herpes. It wasn’t nearly as successful. It decreased the incidence of herpes, but it didn’t completely eliminate it. And that reduction was seen only in women. For some reason, men had the same rates of herpes infections whether they were vaccinated or not. The researchers speculate that it might have something to do with the differences in the skin of the penis and the vagina. The penis has a tougher outerskin layer than the vagina, which is where most women get their infections. You would think that the better skin barrier in men would protect them more from the disease, but it turns out that the vagina compensates for its thin skin with secretions bathed in white blood cells and proteins that help confer immunity against infections. It’s only a theory, but it could be that the vaccine boosts that immunity against the herpes virus in women, whereas men don’t have that advantage.

So, testing the HPV vaccine in men may be a worthwhile objective. The consequences of male HPV infection aren’t as devastating as the worldwide incidence of cervicial cancer is, but it does have implications for transmission of the virus, especially among same sex partners.

Broken System:Deinonychus and South Knox Bubba have been debating the healthcare insurance issue (neither of their archives are working at the moment, be patient and scroll down to “South Knox Bubba on Healthcare” in the case of Deinonychus, and “Insurance Frauds” in the case of SKBubba.)

Meanwhile, Tommy Thompson has turned to the HHS’s scientific advisory panel, otherwise known as the Institute of Medicine, to mull over the same issue:

The National Academy of Sciences said today that the United States health care system was in crisis and that the Bush administration should immediately test possible solutions, including universal insurance coverage and no-fault payment for medical malpractice, in a handful of states.

The thought of the Institute of Medicine offering solutions for the healthcare insurance “crisis” fills me with trepidation, and I haven’t yet had the time to read the full report, but from the media quotes, it sounds as if they’ve recommended a surprisingly reasonable approach to it:

The panel suggested that three to five states pursue the goal of affordable "coverage for all citizens and legal residents," by providing tax credits or expanding Medicaid or the Children's Health Insurance Program.

"We learned in 1993 and 1994 that you cannot be prescriptive," said Gail Warden, president of the Henry Ford Health System in Detroit, who was chairman of the panel that wrote the report.

The 16-member panel proposed pilot projects in four other areas: medical malpractice, community health centers, treatment of chronic illnesses and information technology, to computerize medical records and reduce paperwork. The panel, which included doctors, lawyers, a nurse and several professors, did not estimate the costs of its proposals.

Then, there’s this excellent medical blog, ViewFromTheHeart, by a critical care nurse, who wrote to say that the hospice figures from the Last Act survey on dying in America are indeed skewed toward in-hospital hospice programs:

The statistics are biased for onsite hospice programs; Oregon has over
500 hospice programs but almost none of them are associated with a
hospital so the state was given a relatively poor grade in that regard.

CORRECTION: Alwin Hawkins emailed to say he made a typo. The figure for hospices in Oregon should be 50 not 500.

Supplement Watch: There is, at last, some movement to regulate herbal medicines, but mostly within the private sector. Three companies are offering "seals of approval" to certify that herbal products are free of contaminants, not that they're safe or effective. The FDA is also working on some rules for the basic manufacture of herbal medicines. At least it might keep people from developing lead poisoning from their herbs, although it won't keep them safe from the side effects and possible interactions with other drugs.

Number Numbskulls: A study in JAMA says that taking hormones accelerates heart disease in women. At least that's what the headlines say, and that's what the researchers are telling reporters, even as they say in the same breath that there it isn't so:

In fact, heart disease appeared to progress more quickly in women who took hormones, high doses of vitamins E and C, or both, than in those on placebos. That finding was not statistically significant, but the researchers said the trend was worrisome [emphasis mine]

If it isn't statistically significant, then it certainly isn't clinically significant, as the results make clear:

The new study, to appear on Wednesday in The Journal of the American Medical Association, involved 423 postmenopausal heart patients over three years. By its end, 2 women on placebos had died, compared with 4 who took hormones, 6 who took high doses of vitamins C and E, and 10 who took both vitamins and hormones.

So why are they shouting from the mountaintops that hormones accelerate heart disease?

You can read the abstract here. (And for a handsome price, the whole article, too.)

Although more than 70 percent of Americans say they would like to die at home, only 25 percent of them do. The rest are often hooked up to machines in intensive care units, the report says.

About half of all deaths occur in hospitals, but fewer than 60 percent of hospitals offer specialized end-of-life services. Only 14 percent offer palliative care, which means special care to make sure a dying person is comfortable without working to extend a doomed life.

....Just 23 percent of hospitals offer hospice care, which is designed to do just this.

"Most states have only fair hospice use, with about 12 to 25 percent of deaths including a hospice stay," the report says.

Most dying people get only a week in a hospice, when 60 days would be much better, the group found.

..."In any given state, at least one in four nursing-home residents is experiencing pain for at least two months without appropriate pain management," the report says.

"A study of cancer patients in the ICU found that 55 to 75 percent had moderate to severe pain, discomfort, anxiety, sleep disturbance or unsatisfied hunger or thirst."

A survey of 1,000 adults, done by Lake, Snell Perry and Associates for the group, found that 75 percent had lost a loved on in the past five years. Sixty percent of those surveyed gave the U.S. health care system a rating of fair or lower, and 25 percent said it was poor.

It found that 93 percent believed improving end-of-life care was important.

God, that sounds horrible. But, I’d like to know more about those people. Sure, most people, if asked, will say that they prefer to die at home, but then most people, when acutely ill with congestive heart failure or pneumonia, or an exacerbation of emphysema, or in the throes of a heart attack, want to be taken to the hospital and treated.

Reading this, I couldn’t help but think of one of my patients with very severe emphysema. I’ve discussed end-of-life issues with her, and she says she doesn’t want any heroic efforts. But every time I have to put her in the hospital, I ask if she would want to be put on a ventilator if things get really bad and she says “yes,” even though I remind her that there’s a good chance she may never come off of it once she goes on. Her reply is, “If there’s even a small chance of making it, I want to take it.” So, while she has an ideal vision for her death, it’s only for the death that she sees far in the future, not the death that’s confronting her in the here and now.

That’s why this survey is more than a little cagey. It compares the ideal with reality. It’s like asking people what they wish their yearly earnings were, comparing that figure to the amount they actually make, and then criticizing the economy because the two don’t match.

In that gulf between the ideal and the reality lies the universal fear of facing death. To be enrolled in hospice, a patient has to decide to forgo all further treatment. This is a tough decision for a lot of people. Even cancer patients often want to keep on trying “one more thing” in hopes of prolonging the inevitable. It’s even harder when the illness isn’t something as final as cancer. Patients with congestive heart failure and emphysema, for example, go through a series of disease exacerbations that leave them weaker than before, but still functioning. It’s difficult to know which of those exacerbations is going to be the final one, and most people don’t want to give up until there’s absolutely no hope.

There are other problems with it, too. As Gruntdoc points out, a significant proportion of those people who “die in the hospital,” are found dead at home and then declared dead in the hospital emergency room. They get classified as a hospital death, not a home death. I was surprised, though, by the low number quoted for hospice care at hospitals, and again I wonder if that’s a matter of classification. When they say that “just 23 percent of hospitals offer hospice care,” does that mean the hospice has to be on the hospital premises and run by the hospital to qualify? Our community has a wonderful hospice program, but it’s separate from the hospital. And that isn’t to the detriment of the patient, either. The hospice is a much more pleasant environment - more like a five star hotel than a hospital. Each room has French doors that open out onto a garden, and there’s room for the family to all fit comfortably around the patient. And no matter what time of day or night you call them, someone will come to the hospital to assess the patient and enroll them in the program if needed. Usually, within one or two hours of calling them, the patient gets transferred. I suspect that there are a lot of communities who have arrangements like this, and that the numbers from Last Acts are on the short side of reality.

Gruntdoc mentions another aspect of end-of-life care, though, that’s also very important - advance directives. His impression is that doctors don’t discuss this enough with their patients. There’s probably some truth to that. There’s only a limited amount of time to spend at each visit with someone, and a lot of it gets taken up with other issues that need to be addressed, especially in the elderly. Then, too, a lot of patients shy away from the discussion. They just don’t want to think about it, or they suspect that your motive is to do them in. Even patients with end-stage chronic diseases often get upset when you mention it, taking it as a signal that you're giving up on them.

Then, there are the people who discuss the issue with their physician, but never with their families. They just find it too difficult to do. Again, my patient with severe emphysema comes to mind. Her daughter didn’t realize how serious her mother’s illness was until she happened to be present one day when her mother had to be admitted. When I asked her mother my usual question about life support, it made both the patient and the daughter cry. It’s better that the issue was brought out into the open, but there are a lot of families where it never is.

And Then There’s the Pain: One of the more disturbing things about the report, is its summation of the status of pain in the dying and the hospitalized. This always seems to be the true issue underlying every death activist group. They see the elimination of all complaints of pain as the ultimate goal. But, as I’ve discussed before, pain isn’t that simple. Complaints of pain don’t equate with true pain. Look at JFK. He didn’t complain a lot, but all those around him could see that he was in pain. If the death activists had their way, he would have been euthanized. Then, there’s the opposite side of the coin - the people who complain vocally about even the most minor pain. They walk and talk without any difficulty, but if you ask them, they’ll go into great detail about the amount of pain they’re having. It’s their only topic of conversation. Sometimes, it’s their only means for getting attention. To say that one in four nursing home patients have untreated pain for at least two months at a time doesn’t really tell us much about the state of nursing homes. I would be much more concerned if nursing homes were putting people on higher and higher morphine doses until they stopped complaining. Too often, that point would only come when they stopped breathing, although it would probably be a relief to everyone who has to listen to the complaints.

And that’s what makes me most leary of these death activist groups. Are they really concerned with quality of life issues, or is their primary goal to achieve the acceptance of euthanasia?

Anatomy of an Illness: The Atlantic Monthly article about JFK's medical history isn’t available online, but an interview with the author is. The article itself is very good, and worth reading. It details the symptoms and treatments that Kennedy went through beginning in childhood. He suffered severe bouts of diarrhea and rectal bleeding and had trouble gaining weight.- all the hallmarks of an inflammatory bowel disease, such as Crohn's disease or ulcerative colitis. Although we don’t know with certainty what causes these conditions, they are both within the realm of autoimmune diseases - diseases in which the body’s immune system appears to turn on itself and cause inflammation in organs. Both Crohn’s and ulcerative colitis can be associated with inflammation in the joints and back (arthritis), as well as osteoporosis, and anemia - all of which JFK had. Most cases of Addison's disease are also believed to be autoimmune in origin, although in Kennedy’s case this may have been exacerbated by the steroids he took to try to control the colitis.

If you’ve ever had a bad case of an intestinal virus, then you can begin to imagine how badly he must have felt most of the time. Add to that the pain from the compression fractures of his back and what sounds like pinched nerves from degenerative disc disease, and his body’s innate inability to respond to physical stress due to his Addison’s disease, and the amount of suffering is mind boggling. The article mentions that he was barely able to walk up and down stairs. It’s difficult to imagine how anyone could endure such suffering, let alone pose for those vigorous photographs - playing football, sailing a boat, frolicking in the ocean. Now we know why those who worked closely with him came to regard him with an almost saintly reverence. Then, too, it makes one wonder if those tales of sexual exploits were true or just propaganda. In the interview, the author speculates:

One question that people constantly ask me is how he was able to perform these supposed Herculean feats as a sex machine, given the fact that he had serious back problems and so many illnesses. The answer may be that he carried on quite a bit in the White House swimming pool and (it's alleged) in the bathtub, and that he would practice sex in a supine position—taking the bottom position. This may explain somewhat how he was able to acquire such a reputation as a sexual athlete.

Whatever you might think about the man, his morals, or his use of drugs, you have to admire his tenacity in the face of illness. He certainly didn’t let it get in the way of living.

ADDENDUM: For a comprehensive synopsis of all the Presidents’ health click here.

It's Not Easy Being Green: A reader sent me this link to the Science and Environmental Heatlh Network, which has launched a new movement, Ecological Medicine. The folks at SEHN are certainly a wacky and wild bunch, as this description of one of their thought-provoking staff meetings illustrates:

It’s always dangerous to hold staff or board meetings at the Science and Environmental Health Network because someone might ask a question that will launch entire new projects or turn our thinking inside out. ...One day we asked, “What would a learning disorder look like in a Florida panther? What would a reproductive disorder look like in a Burr oak tree?”

No hint as to what kind of projects those questions resulted in, unless ecological medicine means we should treat panthers and oak trees as people.

Tuesday, November 19, 2002

Parental Rights vs. Medical Sense: A judge in Canton, Ohio, has ruled that parents have the right to choose alternative therapy over conventional therapy for their son’s leukemia. Personally, I think the parent’s have made the wrong choice, but I have to agree with the judge that it’s their right to make that choice:

His decision says the Canton Township couple has the right to use a certified holistic doctor and that it is not the court's place to determine whether the alternative treatment will be effective.

``This court cannot find as a matter of law that the treatment option exercised by these informed and caring parents is improper treatment,'' Stucki wrote. ``These are not parents who refused medical treatment or who elected to take Noah to a witch doctor or a shaman, or some other method of treatment which is not recognized by the medical community as legitimate.''

Stucki noted in his ruling that survival for leukemia patients treated in the usual way is not assured and that the chemotherapy can have long-term toxic side effects on the child.

...``The last thing (the Maxins) need is to simultaneously do battle with the medical and legal community over their own well-informed, researched and compassionate decisions regarding medical care for Noah,'' the judge wrote.

If the conventional therapy they were rejecting offered a 100% cure with a very low incidence of side effects, I would probably feel differently about this, but the truth is, the treatment has a high incidence of toxic side effects, has to be taken for three and a half years, and has an 85% cure rate. Even if the parents opted for no treatment, I think it would be within their rights to do so.

A lot of physicians will disagree with me on this. I know doctors who dismiss patients from their practices if they refuse to immunize their children. And I know doctors who report parents to Children’s Services if they admit to as much as spanking their children. But, they truly do a disservice to their patients by taking such an authoritarian approach. In the end, most parents are better qualified to make decisions about their children’s care than the state. We should reserve the state action for the truly negligent and abusive, not merely those whose decisions and parenting philosophy we disagree with.

Inflammation: C-reactive protein as a marker for heart disease is in the news again. A new trial is going to be launched in 2003:

The study hopes to follow 15,000 patients for three to four years. Ridker said the study will comprise men over 55 and women over 65 who have no evidence of heart disease.

All study participants must have an LDL, or "bad cholesterol" level, of less than 130 and a CRP level of less than two. Patients in the multi-site, randomized study will not know whether they are taking a placebo or the drug rosuvastatin.

Rosuvastatin is made by AstraZeneca and received approval this month for use in the Netherlands. It has not been approved for use in the United States. The U.S. Food and Drug Administration is overseeing the clinical trial, which is being sponsored by the drugmaker.

Meanwhile, the normally statin-boosterish American Heart Association has some uncharacteristically cautious words on the subject:

"When we have new information we need to evaluate it very carefully before making recommendations to physicians and to the public about how to deal with this new information because you don't want to make a strong recommendation now, only to get new information in the future that may suggest that the initial recommendation was not correct," Dr. Robert Bonow, president of the American Heart Association, cautioned. He said more research is needed even while all research on CRP is being reviewed.

Exactly. Hopefully, Dr. Ridker will be more forthcoming with his data than he was in the study he published last week.

Believe It or Not: My physicist husband had a "spit-out your coffee" moment this morning when he read this headline in our local paper: `Cold' laser treatment aids carpal tunnel syndrome. The photograph, which isn't in the web-version, shows what looks like a flashlight with a red beam, like those laser pointers people use for presentations. Here's the explanation of the physics behind it:

Lasers that produce heat also destroy tissue. The cold laser uses a different wavelength of light, so it is able to penetrate deep into tissue without destroying it.

Now, I'm a physics moron, so I have to take my husband's word on this, but he finds it highly unlikely that any wavelength could penetrate through the skin to reach the molecules in the tendons without being powerful enough to burn through it. And I have to admit, this sounds suspiciously like those magnet devices to me. Yet, it has FDA approval:

Wesley was one of the places that tested the Microlight, which won federal Food and Drug Administration approval earlier this year. In Wesley's study, which began in 1996, the Microlight allowed 78 percent of the 45 patients treated to return to normal activities.

Placebo effect? Probably. Aetna says it’s bunk, and they list the references to back it up. Then, too, the same technology is used at spas as a promised wrinkle treatment. Maybe the FDA didn’t do so well in physics, either. (Before I get any emails in defense of the FDA, I realize they don't concern themselves with the mechanisms of action, only with the studies showing whether or not a device helps or harms.)

Insurance Conundrum: A reader sent along this email about health insurance and Oregon:

Since I am not a screaming liberal or "hard line health care universlaist" ( though my father-in-law may disagree) but having a deep concern for our present mechanisms for financing health care I offer the following as a brief counter point to the editorial you posted regarding the failure of the single payer proposal in Oregon. From today’s Oregonian Business News: "

In Oregon, voters overwhelmingly rejected a measure to create a single statewide health plan for all residents. The measure, which would have required at least $10 billion a year in taxes, failed by nearly a 4-1 ratio.

And faced with a worsening budget shortfall, state lawmakers last week eliminated coverage of mental health and several other services for about 100,000 low-income residents covered by the Oregon Health Plan. Lawmakers also delayed, potentially indefinitely, the start of the biggest expansion of the state and federally funded coverage since 1994.

"The kind of expansion we had hoped for likely will not occur," says Jean Thorne, director of the state Office of Medical Assistance Programs, who will keep her post when Governor-elect Ted Kulongoski takes office.

Soaring premiums, meanwhile, are making coverage increasingly unaffordable for employers and individuals. For Portland-area businesses and their workers, average health costs will jump by more than 15 percent to $5,510 per employee next year, predicts benefit consultant Hewitt Associates. That follows a 14 percent average increase this year and a 13 percent increase the year before. Among the area's small employers, traditional health insurance for workers and families now averages more than $10,000 a year.

People who've lost insurance are adding to the burden of businesses and individuals who buy coverage. Oregon's uninsured, estimated at 444,000 children and adults, are crowding free clinics and hospital emergency rooms. Hospitals and other caregivers recover the costs of uncompensated care by charging higher fees to private insurers. " [ed. note - I wasn’t able to link to the original article, it was no longer on the web page.]

Single payer, multiple payer, some time payer, what have you--I was disappointed in your brief dismissal of the Oregon results by posting an editorial with limited perspective and no alternative solutions: There are serious financing problems and little substantial discussion of pragmatic solutions:

1) The cost of administering health care insurance plans is only 2-3% less that we spend on pharmaceuticals (about 8% of total health dollars)--if one wants to be outraged about health care costs give pharmaceutical companies a break--at least they help patients--these costs do not even include the billions of dollars spent by providers supporting medical records and IT systems to manage billing responsibilities

2) Some one is paying for the a significant portion of the health care for medically indigent--it is employers and tax payers--is this really the way you want to go in assuring limited access--hiding the costs in private premiums and State/Federal Plans-

3) An employer driven system that depends on private insurance is intrinsically plagued by issues completely unrelated to the persons need for health care--swings in the economy, business closures and relocations, union strength, commercial economic incentives, a patch work of regulatory rules, the personal values of the employer,etc--

The list could go on and on--The point is--basic reform of some type is inevitable--do I personally support the Oregon plan--I have no idea--but States will be, and probably need to be, the source of imaginative health care reform--

I agree that our current employer-driven system is a poor model, but I don’t think the solution is a state-run insurance program. Whenever the state decides to run things, politics insinuates itself into even the most rudimentary decisions and policies. That’s one reason we have had such ludicrous spectacles as Congressional hearings on the value of mammograms - because Medicare pays for them. The other thing that happens when the state pays for healthcare is that everyone expects equal treatment, regardless of their ability to pay. Again, Medicare is an example. I have plenty of Medicare patients who own two homes, travel extensively, and yet still manage to carp about the twenty percent they have to pay of a fifty dollar office bill. Then, look at the efforts to get prescription coverage for the elderly. Congress can’t seem to bring themselves to limit the benefit to the truly needy, but instead are considering plans to extend the charity to everyone. It makes no sense for taxpayers to support the wealthy.

A better system would be to have health insurance work more like car and home-owner’s insurance. The routine stuff, like office visits, medication for acute illnesses, and preventive health should be paid out-of-pocket by the majority of us. Insurance would kick in for the more expensive stuff, and you could buy policies that have different limits - say, $1,000 or $2,000, etc. Right now, catastrophic health insurance isn’t available. The trend has been too much toward covering everything, which is why insurance rates are going through the roof. But, a plan like that would be much more affordable for everyone - for employers who offer it as a benefit and for the self-employed. The only role I see the state playing in insurance is in providing it for the poor, and perhaps in paying for things that are of true public health import such as childhood immunizations or influenza vaccines.

Some sort of reform is going to be needed, but I hope it comes from the insurance industry rather than government. I’m not surprised that Oregon is now having to cut back on their Health Plan for the poor. They were having trouble before the election, yet in the weeks before the election, advocates of the single-payer system were holding it up as a financial success. Now that the issue has been defeated, Oregon Health Plan’s in trouble again. It makes it look like the single-payer issue was a means to get more tax dollars for the Oregon Health Plan, but the only way they felt they could do it was to offer the benefit to everyone.

Monday, November 18, 2002

Healing Hearts: In an experimental procedure, doctors are healing dead heart tissue with immature skeletal muscle cells. Now that's exciting, although it isn't at all certain that having the new tissue improves the heart's function:

For now, all researchers can say for sure is that the transferred cells take root and flourish in dead areas of the heart. Whether they make the heart pump more forcefully remains to be seen, although researchers say they see encouraging evidence this may happen.

If they do prove successful, this would certainly be one of the greatest breakthroughs in medicine.

These medical records do not include additional drugs from Max Jacobson, who later lost his license for prescribing amphetamines. (In 1972, Times reporters Martin Tolchin and Dr. Lawrence Altman - pursuing a tip about Vice President Spiro Agnew that never panned out - followed the trail that led to the earlier supply of speed by "Dr. Feelgood" to the Kennedy White House.)

Hyper in Diapers: The Sunday Times Magazine also had a well-balanced account of using Ritalin in preschoolers. Attention Deficit Disorder is extremely difficult to diagnose. There is definitely a tendency for adults who can’t set limits on their children to turn to drugs as a quick fix, as some of those interviewed for the article point out:

'We have an obsession with performance in our country,'' says Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., and the author of two books on A.D.H.D. ''We have a universal performance enhancer in Ritalin. It helps anyone, child or adult, A.D.H.D. or not, to perform better. It was inevitable that there would be this drift down to the 3- to 5-year-old set.''

That’s true. I have had adults ask me for it, too, because they have trouble concentrating and are convinced they have ADD. I always refer them out to a psychiatrist for evaluation, though, largely because I’m only all too well aware that I could stay up later and concentrate better if I took amphetamines, too, and I know I don’t have ADD.

Flipping through the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders on a recent afternoon, Breggin read aloud from its list of A.D.H.D. symptoms: ''Often fails to give close attention to details or makes careless mistakes in schoolwork. Often fidgets with hands or feet or squirms in seat. Often blurts out answers before questions have been completed.'' He scowled.

''There is no disease,'' he said flatly. ''It's a list of behaviors that annoy adults.''

That’s true, too. It’s the “something has got to be done but not by me” syndrome of teachers and parents.

Having said that, however, there are also genuine cases of ADD, such as the boy described in the article. Some kids just seem to be wired wrong and certainly benefit from medication. They are in the minority, however. I worry about the kids who are given drugs more to help their parents than to help themselves. Are we denying ourselves future explorers and heroes by taking away their sense of adventure and daring? Only time will tell.

Battered Truth: The New York Times Sunday Magazine had a long, sensible article on the issue of domestic violence. It correctly points out that violence isn’t all one-sided:

Right from the start, Michael found himself falling into familiar patterns with Sylvia. ''The distrust of a woman -- I had it deep,'' he says. ''I physically abused my first wife -- smacks, punches, kicks. And then I turned around and did it again with Sylvia. The least little thing, I would fight her. I would hurt her. And she didn't deserve none of it.'' Speaking now as a sober-minded 41-year-old, after all he has been through and more precisely all he has put others through, Michael is trying hard to shoulder full responsibility for his actions.

Sylvia, however, argues that the dynamic was mutual all along. Michael wasn't the only one who had issues, she says. When they met, she had just escaped from a violent relationship that deteriorated to the point where the man was stalking her, armed with a knife. She was defensive and her fuse was short. ''It's inaccurate to say only that Michael would beat me,'' Sylvia says, more forgiving of Michael than he is of himself. ''He did. But we would beat each other. We would destroy the house. It became kind of dangerous for both of us. I didn't know who was going to kill who.''

This is true in the majority of domestic violence cases. You have two people who fight, tempers flare, neither are able to control their impulses, and boom - they end up hitting each other. Few women are the docile and innocent lambs that the media and feminist groups have portrayed them to be. Dealing with the problems that both parties bring to the table rather than putting the blame on men only makes sense, and would certainly be a more effective solution. It also makes it possible to address the problem of domestic violence between same sex partners more effectively.

Sunday, November 17, 2002

Presidential Pills: The New York Times runs through John F. Kennedy's health history today. In the era of "mother's little helper", we shouldn't be all that surprised at the mix of uppers and downers his doctors gave him:

In December 1962, after Jacqueline Kennedy complained that he seemed "depressed" from taking antihistamines for food allergies, he took a prescribed antianxiety drug, Stelazine, for two days. At other times he took similar medications regularly.

The records show that Kennedy variously took codeine, Demerol and methadone for pain; Ritalin, a stimulant; meprobamate and librium for anxiety; barbiturates for sleep; thyroid hormone; and injections of a blood derivative, gamma globulin, presumably to combat infections.

In the White House, Kennedy received "seven to eight injections of procaine in his back in the same sitting" before news conferences and other events, Dr. Kelman said.

Kennedy did indeed have a serious illness, Addison's disease, and he was on steroids on and off for most of his life, which would weaken his bones and make him prone to the stress fractures in his back that the article mentions. Still, his doctor, Janet G. Travell did come in for quite a bit of criticism of her management of him. It’s never a good sign when someone’s taking sedatives and stimulants at the same time. It’s the Judy Garland syndrome. Give them stimulants to keep them going and sedatives to bring them down. It’s a marvel that he was able to function at all.